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Value-Based Payment Program
Overview Webinar
Kristen Presleigh, MPHQuality Improvement Program Advisor
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
2020 VALUE-BASED PAYMENT PROGRAM OVERVIEW
VALUE-BASED PAYMENT PROGRAM
• Incentive payments for specific measures
• Implemented 7/1/2019
• Aimed at improving care for high-cost and high-need populations
• FQHC/RHC are excluded from payment
Targeted Areas:
• Prenatal/postpartum care
• Early childhood preventive care
• Chronic disease management
• Behavioral health integration
Measure Type Measure
Prenatal/Postpartum Care
Prenatal Pertussis Vaccine
Prenatal Care Visits*
Postpartum Care Visits*
Postpartum Birth Control
Childhood Preventive
Care
Well Child Visits in the First 15 Months*
Well Child Visits in the 3rd-6th Years of Life*
All Childhood Vaccines for Two Year Olds *
Blood Lead Screening
Dental Fluoride Varnish
2020 VALUE-BASED PAYMENT PROGRAM
* 2020 CBI Measures
2020 VALUE-BASED PAYMENT PROGRAM
Measure Type Measure
Chronic Disease
Management
Adult Influenza (Flu) Vaccine
Controlling High Blood Pressure*
Control of Persistent Asthma*
Diabetes Care*
Tobacco Use Screening
Behavioral Health
Integration
Management of Depression Medication*
Screening for Clinical Depression
Screening for Unhealthy Alcohol use*
* 2020 CBI Measures
2020 VALUE-BASED PAYMENT PROGRAM: ENHANCED PAYMENT
ENHANCED PAYMENT FACTOR
• Providers will receive an enhanced payment for services provided to members with:
• Substance Use Disorder
• AOD Abuse and Dependence Value Set
• Serious Mental Illness
• Schizophrenia Value Set
• Bipolar Disorder Value Set
• Other Bipolar Value Set
• Major Depression Value Set
• Homelessness
• Z59.0 – Homeless
• Z59.1 – Inadequate Housing
• Diagnoses come from CMS Core Measure Sets
• Payment to linked PCP
• Payment for CBI enrolled PCP
providers
• Eligible for Data Submission
Tool
• Alliance maintained code set
• Care coordination and quality
measures are programmatic
based on a rate
• Payment to rendering
provider
• Payment for all in-network
providers
• Ineligible for Data Submission
Tool
• State maintained code set
• Paid on a per claim basis, with
certain limitations
2020 VALUE-BASED PAYMENT PROGRAM
CBI vs. VBP
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
PRENATAL/POSTPARTUM CARE
PRENATAL PERTUSSIS VACCINE
• Measure Description: Incentive
payment to providers for members
who received a Tdap vaccine with a
pregnancy supervision ICD-10 code at
anytime during the measurement year
Coding:
PRENATAL/POSTPARTUM CARE
PRENATAL CARE VISIT
• Measure Description: Incentive
payment to providers for members
who received a prenatal visit in their
PCP/OBGYN in the first trimester (by
the end of the 13th week), or within 42
days of enrollment with the Alliance.
Coding:
* 2020 CBI Measure
PRENATAL/POSTPARTUM CARE
POSTPARTUM CARE VISITS
• Measure Description: Incentive payment to providers for members who receive a postpartum visit on or between 1 and 84 days after delivery.
• Early Postpartum Visit: Postpartum visit on or between 1 and 21 days after delivery
• Late Postpartum Visit: Postpartum visit on or between 22 and 84 days after delivery
Coding:
* 2020 CBI Measure
PRENATAL/POSTPARTUM CARE
POSTPARTUM BIRTH CONTROL
• Measure Description: Incentive payment to
rendering or prescribing provider for provision of
most effective, moderately effective, or long-
acting reversible methods of contraception
within 60 days after delivery.
• One payment per delivery
Coding:
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
EARLY CHILDHOOD
Measure Description: Separate incentive
payment to a provider for each of the last
three well child visits out of eight total - 6th,
7th and 8th visits.
WELL CHILD VISITS IN FIRST 15 MONTHS OF LIFE
Coding:
• CPT Codes: 99381-99382, 99391-99392, OR
• ICD-10 Codes: Z00.110-Z00.129, Z02.0, Z02.82,
Z76.1, Z76.2
Bright Futures Periodicity Schedule: https://www.aap.org/en-
us/Documents/periodicity_schedule.pdf
* 2020 CBI Measures
EARLY CHILDHOOD
Measure Description: Separate
incentive payment to a provider for
completing each of the annual well
child visits at age 3, 4, 5 and 6.
WELL CHILD VISITS IN 3rd – 6th YEARS OF LIFE
Coding:
• CPT Codes: 99382-99383; 99392-99393
• ICD-10 Codes: Z00.110-Z00.129, Z02.0, Z02.82, Z76.1, Z76.2
Bright Futures Periodicity Schedule: https://www.aap.org/en-us/Documents/periodicity_schedule.pdf * 2020 CBI Measures
ALL CHILDHOOD VACCINES FOR TWO YEARS OLD
EARLY CHILDHOOD
Vaccines Number of Doses
Hep B 3
Polio 3
HIB 3
DTap 4
PCV 4
Rotavirus 2 or 3**
Influenza 2
Measure Description: Members
who received the last does in any
of the multiple dose vaccine
series given on or before their
second birthday.
** Number of doses depends on brand of vaccine
* 2020 CBI Measures
EARLY CHILDHOOD
Promote“Same Day, Same Way”
Administer all vaccines due
during the office visit
Immunization Registries
Clinics are required to
input all vaccines
Chart Prep
Prior to visits, review chart
to avoid missed
opportunities
Immunization Schedule
Provide members with a copy of the CDC vaccine
schedule
CDC Vaccine Schedule – English: https://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf
CDC Vaccine Schedule – Spanish: https://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf
EARLY CHILDHOOD
Measure Description: Incentive
payment for blood lead screening
in children up to two years of age
BLOOD LEAD SCREENING
• Payment for each occurrence
on or before the 2nd birthday
• Eligible code: 83655
EARLY CHILDHOOD
APPLICATION OF DENTAL FLUORIDE VARNISH
Measure Description: Incentive payment for topical fluoride varnish
applications for children ages 6 months - 5 years. Payments given for the
first four visits in a 12 month period.
Helpful Tips:• Providers and staff should be trained to perform
fluoride varnish treatments
• Contact your local CHDP to schedule staff
training
• Eligible Codes:
CPT – 99188 or HCPCS – D1206
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
ADULT INFLUENZA VACCINE
Measure Description: Incentive payment to a
provider for ensuring influenza vaccine
administered to members 19 years and older
CHRONIC DISEASE MANAGEMENT
Payment Frequency:
• Payment to rendering provider for up to two flu shots
• One payment per patient in first quarter of the year (January-March)
• One payment per patient in fourth quarter of the year (October-December)
CHRONIC DISEASE MANAGEMENT
CONTROLLING HIGH BLOOD PRESSURE
Measure Description: Incentive payment for
each event of adequately controlled blood
pressure (<140/90 mm Hg) for members 18 -
85 years old with a hypertension diagnosis.
• Payment to each rendering provider for a non-emergent
outpatient visit with a documented controlled blood
pressure.
• Eligible Codes:
• 3074F: Systolic BP <130 mm Hg
• 3075F: Systolic BP 130-139 mm Hg
• 3078F: Diastolic BP < 80 mm Hg
• 3079F: Diastolic BP 80-89 mm Hg
• I10: Hypertension Diagnosis
CHRONIC DISEASE MANAGEMENT
CONTROL OF PERSISTENT ASTHMA
Measure Description: Incentive
payment for members 5 - 64 years
old with diagnosis of asthma with a
prescription of controller medication.
• Payment to each prescribing provider that provided controller asthma
medication for members with a diagnosis of persistent asthma
• Each provider is paid once per year per member
• Asthma ICD10 Value Set : J45.20-J45.998 * 2020 CBI Measures
Measure description: Incentive
payment members 18–75 years of age
with HbA1c testing and test results.
• No more than 4 payments per year
• HbA1c results must be at least 60
days apart.
• Diabetes diagnosis is note required
• Eligible Codes:
o 3044F: HbA1c >7%
o 3045F: HbA1c 7-9%
o 3046F: HbA1c >9%
DIABETES CARE
CHRONIC DISEASE MANAGEMENT
* 2020 CBI Measures
CHRONIC DISEASE MANAGEMENT
TOBACCO USE SCREENING
Measure Description: Incentive
payment to providers for tobacco
use screening or counseling
provided to members 12 years and
older.
• One payment per provider per
member per year
• Eligible codes: 99406, 99407,
4004F, 1036F
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
• One payment per provider per member per
year
• Must be an outpatient visit
• Standardized screening tools: PHQ-2,
PHQ-9, GDS, EPDS (not a complete list)
• Eligible codes: G8431 or G8510
BEHAVIORAL HEALTH INTEGRATION
SCREENING FOR CLINICAL DEPRESSION
Measure Description: Incentive payment for screening for clinical
depression (using a standardized screening tool) for members 12 years
and older
• Payment to prescribing providers for the
Effective Acute Phase Treatment
• Effective Acute Phase Treatment is at least
84 days during 12 weeks of treatment
• One Effective Acute Phase Treatment per
year
BEHAVIORAL HEALTH INTEGRATION
MANAGEMENT OF DEPRESSION MEDICATION
Measure Description: Incentive payment to providers for members 18
years and older with a diagnosis of major depression and newly treated
with an antidepressant medication, and remained on antidepressant
medication for 12 weeks.
* 2020 CBI Measures
• Must use a standardized screening tool
(Audit-C or Single Alcohol Screening
Questions [SASQ])
• One payment per provider, per member, per
year
• Eligible codes: G0442 and G0443
BEHAVIORAL HEALTH INTEGRATION
SCREENING FOR UNHEALTHY ALCOHOL USE
Measure Description: Incentive payment to provider for screening
members 18 years and older for unhealthy alcohol use.
* 2020 CBI Measures
Today’s Agenda
01 Program Overview
02 Prenatal/Postpartum Care
03 Early Childhood
04 Chronic Disease Management
05 Behavioral Health Integration
06 Resources
RESOURCES
PROVIDER PORTAL UPDATE: NEW & UPDATED CBI REPORTS
New Quality Monthly Reports
High ED Utilizer Report
Childhood Immunizations (Combo 10) Dashboard
CBI Forensics – Updated
CBI Dashboard – Updated
RESOURCES
RESOURCES
Provider Webpage
• Incentive Summary
• Tip sheets
• CBI Technical Specifications
Provider Portal
• CBI Dashboard
• CBI Forensics Report
• Quality Reports
• Data Submission Tool
Quality Improvement
Team
• Practice Coaching
• CBI Forensics
Care Management
• Care ManagementWebsite
RESOURCES
OTHER RESOURCES
• CCAH Depression Tool Kit: http://www.ccah-
alliance.org/providerspdfs/Depression_Toolkit.pdf
• DHCS Value Based Payment Program:
https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx
• Bright Futures Periodicity Schedule: https://www.aap.org/en-
us/documents/periodicity_schedule.pdf
• CMS Core Measure Sets: https://www.medicaid.gov/license-
agreement.html?file=%2Fmedicaid%2Fquality-of-
care%2Fdownloads%2F2019-adult-non-hedis-value-set-directory.zip
• CCAH Adult Immunizations Webinar: https://www.ccah-
alliance.org/workshops.html
